Welcome to the July 2007 edition of The SPD Companion Newsletter. Today's topic? SPD and Potty Training.

For so many, this combination goes together as well as oil and water. I want you to know the difficulties you are experiencing, have experienced, or will experience with this major developmental task are NOT your “fault” nor your child's. In order to truly understand why I say this, we must take a good hard look at the way SPD affects a “new sense” you may be less familiar with.

We all know the typical 5 senses; vision, hearing, smell, touch(tactile), and taste. If you are familiar with Sensory Processing Disorders, you most likely know about, and hopefully understand, two more important senses; the vestibular and proprioceptive senses.

Now, we will add one more sense to these previous 7... the interoceptive sense. It is a well known sense to those who research and study neurobiology. But, it is far less talked about than the other senses. It is time to start talking about and understanding it IF we are to truly understand the inner struggles our SPD children must contend with. We also must understand this sense so we know why they do what they do and how we can help them.

Traditional methods for potty training will not work with these kids, as many of you may have already found out!

The Interoceptive Sense:

The interoceptive sense refers to the “body-centered sensory systems”, the “near senses”, which operate without conscious thought and cannot be observed. The interoceptive sense relates to the “sensory nerve cells innervating the viscera (thoracic, abdominal, pelvic organs, and cardiovascular system), their sensory end organs, or the information they convey to the spinal cord and the brain.”
(from www.answers.com medical dictionary, 2007)

Therefore, the interoceptive sense includes input regarding the following:

heart rate

thirst

hunger

digestion

state of arousal

mood

temperature

respiration

bowel and bladder

Considering all the innervations of the internal visceral organs via the interoceptive sense, is it ANY surprise our SPD kiddos (and adults) may have difficulty in more areas than we even thought (or knew, but didn't know WHY)? Can you also now see how many of these kids are easily MISDIAGNOSED? If we isolate each of these and we see problems in these areas, is it no wonder our kids are diagnosed with other physical and mental health diagnoses?

Dr. Lucy Miller, in her book “Sensational Kids”, breaks Sensory Processing Disorder into three main subtypes:

1.“Sensory Modulation Disorder (SMD) is a problem with turning sensory messages into controlled behaviors that match the nature and intensity of the sensory information.” This would include sensory over-responsivity, sensory under-responsivity, and sensory seeking/craving behaviors.

2.“Sensory-Based Motor Disorder (SBMD) is a problem with stabilizing, moving, or planning a series of movements in response to sensory demands.” This would include dyspraxia and postural disorders.

Thinking about each of the above mentioned carefully, we can then understand how each of these subtypes, when disordered/inefficient, could lead to difficulties in the interoceptive sense. These may include:

becoming too hot or too cold, sooner than others in the same environments

difficulty in extreme temperatures or going from one extreme to another (i.e., winter, summer, going from air conditioning to outside heat, a heated house to the cold outside)

respiration that is too fast, too slow, or cannot switch from one to the other easily as the body demands an appropriate response

heart rate that speeds up or slows down too fast or too slow based on the demands imposed on it

respiration and heart rate that takes longer than what is expected to slow down during or after exertion or fear

severe/several mood swings throughout the day

unpredictable state of arousal or inability to control arousal level (hyper to lethargic, angry to happy in short periods of time, perhaps without visible cause)

frequent constipation or diarrhea, or mixed during the same day or over a few days

difficulty with potty training; does not seem to know when he/she has to go (i.e., cannot feel the necessary sensation that the bowel or bladder are full

unable to regulate thirst; always thirsty, never thirsty, or oscillates back and forth

unable to regulate hunger; eats all the time, won't eat at all, unable to feel full/hungry (prone to eating disorders and/or failure to thrive)

Do you SEE how SPD can affect a child's success with potty training? Given all the sensory information that must be processed efficiently and effectively? Does this make sense? Let's explore specifics about potty training even further.

For most parents, the idea of potty training initiates from several factors. The first... a child's age. We know that between 18 and 36 months “typical” children are developmentally ready to begin this important milestone. This is usually the first reason we start the process. However, as I will explain, this can easily be our first “mistake” in trying to potty train children with SPD or other special needs. A child's chronological age is FAR less important than their “developmental age” or physiological readiness. And it is THIS that we must first understand and take into consideration BEFORE we begin potty training “demands” on our SPD (or special needs) child. A child may be delayed in other areas so we must accept they may be delayed here too.

The second factor that may spark a decision to begin potty training is the cost and inconvenience of diapers. We become anxious about wanting to get rid of this added hassle and expense. We then also assume that as long as they continue wearing a diaper it is too “easy” for the child to keep using this approach for eliminating. Sometimes, we decide to buy Pull-Ups, training pants, or underwear in hopes of training them by way of accidents. This is NOT a good method of potty training SPD kids... it can do more psychological harm than good if they are not developmentally or physiologically ready to potty train.

A third factor that may enter into our decision to start potty training our SPD kids is “peer pressure” on YOU, as a parent. Who is nagging you to get your child potty trained, no matter what the emotional cost to your child? Is it your mother, the in-laws, your friends, the day care, other family members, or your pediatrician? Do they understand SPD? Do they know the real reasons your child may not be ready yet? Do YOU? Do you feel the guilt or “failure” as a parent if your child is not potty trained at the same time as his peers? Do you feel it is your fault? Are you putting unnecessary pressure on your child which is causing fear, control issues, tantrums, defiance, shame, and/or aggressiveness. Motivation by peer pressure (whether on you or your child) is NOT a good method for potty training SPD kids... it can do more harm than good and actually delay this developmental milestone even further.

So, now that we know factors which do NOT work, let's take a look at how SPD affects potty training specifically; THEN we can address methods which WILL work.

Signs Of Physiological, Physical, And Psychological Readiness For Potty Training:

a bowel and bladder that are mature (i.e., can hold larger amounts at one time and can “sense” the need to void/eliminate

staying dry for at least 2 hours at a time (including nap times)

the child can recognize that she is voiding/eliminating (you can also recognize they are by their facial expression, posture, place they go to do it, what they say, etc.)

a “willingness” to sit on the potty (without fear, with or without diaper/clothes still on)

the child is able to walk to/from the bathroom, get on the toilet, sit, balance, and get off the toilet or potty chair with little assistance

able to pull his pants down by himself

can follow simple instructions/directions/commands

is asking to have his wet/dirty diaper changed or to use the potty

your child is having regular bowel movements

It is only AFTER a child is showing most/all of these signs that you will start preparing them for the big task of potty training. In the preparation phase (which experts recommend be for about 3 months) you will begin introducing them to everything involved in potty training. We will talk about this in particular in the Potty Training Tips section in a few minutes.

If we carefully look at the signs of readiness, we can see that there are many ways in which SPD can interfere with potty training. Let's look at these so we can fully understand what may be going on and why potty training an SPD child can indeed be a difficult and developmentally delayed task.

How SPD Can Affect Potty Training

Bowel and bladder readiness is probably the biggest hurdle to successful potty training. However, it is one of the main problems our SPD kids face. It is particularly challenging as many don't understand that THIS trumps chronological age. A child's age will often mislead us into thinking they “should” be ready. But, they will NOT be successful until their bowel/bladder and neurological system is ready.

If an SPD child literally cannot feel sensations from his bowel and/or bladder, or the sensory receptors of this interoceptive sense are not picking up or interpreting messages properly (over or under responsive), the child will not know when/if they have to go the bathroom, or how to effectively control their bowel/bladder muscles for elimination. Their bodies truly do not give them the proper input or signals necessary for effective potty training. It is the same general concept that underlies SPD... the sensory input, neurological organization, or sensory motor output are inefficient.

Because of inefficient sensory processing, these children may...

- go rushing to the bathroom at the very last minute (when they finally feel something) and be too late

- sit on the potty endlessly “trying”, being unable to void/eliminate despite their best efforts

- be unable to control their bladder and/or bowel functions as the sensory receptors are not processing information properly

- get easily frustrated, angry, and perhaps ashamed if they have an accident because they literally could not feel the signals or control their bodily functions

- become frequently constipated or feel “pain” when having a bowel movement

- become resistant to potty training beyond 24-36 months of age

- be unable to tell/feel when they need to, or are, voiding/eliminating; no sense of a “full” bladder/bowel

- be confused, embarrassed, and feel different than other children his age; other kids may indeed pick on him for still being in “diapers” or having accidents

- may never feel distressed by a dirty/wet diaper

- fear sitting on the toilet due to poor muscle tone, postural instability, or poor balance

- be unable to get undressed and get on/off the potty by themselves due to poor sensory-motor issues and coordination

- may gag or become nauseated by the smell of bowel movements or the bathroom in general, thus avoiding or fearing it

- be afraid or fearful of the sound of the toilet flushing

- be uncomfortable on a hard, cold toilet seat

- be uncomfortable with the feeling of rubbing toilet paper on themselves after voiding/eliminating

How To Help The SPD Child With Potty Training

1. Understand their experience may be uniquely different than their peers and/or siblings.

2. Wait to start potty training until they show the psychological and physiological signs of readiness we talked about earlier, despite their age.

3. Go at the CHILD'S pace and give plenty of positive reinforcement.

4. Do not punish or criticize the child for not recognizing their own bodily sensations and/or if they have an accident.

5. Do not potty train during periods of high stress in the child's environment (i.e., new sibling, a move, new day care, starting preschool, etc.).

6. After the child shows signs of physiological and psychological readiness, begin a 3 month preparation phase (minimum) before actually potty training (yes, patience will be the key here!).

7. During potty training preparation phase do the following:

- go to the store (or look online) with your child to pick out a special potty chair

- allow the child to decorate the new potty with stickers

- make a special “big girl/big boy potty basket” with toilet paper and/or flushable wipes, a book or two, stress/relaxation balls, a calming cd, aromatherapy spray or oil, and a sticker reward chart

- have the child watch videos and/or read books to them about potty training (see resources at the end of this newsletter)

- model using the bathroom (preferably with the same sex parent or sibling) and talk about what you do/are doing

- allow the child to become familiar with the toilet or potty chair, even if sitting on it with diaper and/or clothes on

- observe the child's behavior and signs that they are going/have gone in their diaper; make lighthearted comments about it... “Are you peeing/pooping?”; “Can you feel that?”; “Let me know when you want to try doing it on your special potty chair.” “What does it feel like when you have to go/are going potty/poop”, “Does your diaper need to be changed now since you just went pee/poop?” Does your body/belly feel better now that you have peed/pooped, etc.

8. If the child appears to be fearful of pooping in the potty, specifically, empty the poop from the diaper into the potty and have them choose if you or they will flush it down.

9. If your child doesn't appear to notice when he/she needs to go to the bathroom, try a schedule (for example, every 2 hours, 30 minutes after a sizeable drink, after he wakes up, before a bath, etc.) No pressure, just try.

10. Find out what is most comfortable for your child; if you give them privacy in the bathroom, or if you are in there with them.

11. If your child is NOT distressed by, or asking to be changed out of, a wet or soiled diaper do NOT use Pull-Ups. They are just as absorbent as diapers, so they won't feel it with those either. Instead, pick out some “Big Boy/Big Girl” underwear or training pants and have them wear those when THEY are ready to.

12. If your child DOES notice when they are wet/need a diaper change, Pull-Ups are a good next step. They are easy to get up and down, yet still protects them if they have an accident. THEN graduate to underwear the more successful they are.

13. If trying underwear for your child, make sure to notice whether they are bothered by the seams in the underwear. They may refuse to wear them because they are uncomfortable, not because they don't want to work on potty training.

14. If your child is ONLY pooping in their diaper (basically potty trained for peeing) allow them to do so until they are comfortable doing it in the potty. Try to have them do it in the bathroom itself, if possible, then on the toilet with diaper on, then on the toilet with diaper ½ open, then with diaper off and completely on the toilet. Another good tactic is to take the diaper or Pull-Up off after they have had a bowel movement and dump the poop into the toilet. Talk about how that is where it goes, make them feel comfortable about “letting it go” (be silly; make up a song, wave/say goodbye to the poop if you want, etc.), and have them decide who gets to flush it. (Note: most children are indeed bladder and bowel trained at separate times... one will usually come before the other.)

15. Make going potty FUN with food coloring. Put blue food coloring into the water. When they pee in the toilet, their success will change the water to green! Put red food coloring in, and success turns the water orange!

16. Make “aiming” fun for boys with toilet targets! (see link to resources at the end of this newsletter) They are flushable, fun, floating shapes they can use for “target practice”. A great way to teach them, a fun way to learn.

17. Talk to them about the specific sensations they feel revolving around needing to go to the bathroom and actually going. Explain why they have the feelings they do or why it is harder for them to feel than others. Make them as informed as possible, at an age appropriate level, about how their body works, what it feels/doesn't feel, what to do when, etc. Make them aware of sensations and make them feel “normal”. Also let them know you are there for them and will help them in any way they need your help. You are in this together and you will both feel proud when it is accomplished.

18. For the tactile defensive, a padded toilet seat or flushable wipes instead of toilet paper may feel better.

19. Do not push too hard, force the child, punish the child, make them feel ashamed or afraid by your actions or words if things are not going well. Anytime they become significantly resistant and frustrated, take a break for a week or two and slowly try introducing it again. Do not let it become a control issue or power struggle!

20. Above all... be patient, be consistent. Give positive feedback, rewards, and praise. They WILL eventually become potty trained, rest assured. Remember... THEIR timing, not yours.

BESIDES these tips and tricks, IF your child does have SPD, or shows many red flags... make sure an evaluation is done and OT therapy is started. The tricks alone will not help him reorganize his neurological system. They will make things easier and more successful. But, when SPD has significantly impacted the interoceptive sense, OT treatment must be done. It is with therapeutic intervention to reorganize and “rewire” the brain and nervous system that we will see the biggest changes in internal regulation. Specifically, each area of dysfunction will need to be addressed.

One more thing... so far, treatment that has been most effective for internal regulation issues is a combination of SI therapy (whole body approach) and Therapeutic Listening. Studies are desperately needed, but Occupational Therapy for SPD is our best solution, along with the tips listed above, for better success at potty training our SPD kiddos.

As promised, here are the additional resources that will help you potty train your SPD child. Just
click here!

Thank you for spending your precious time with me this month. I truly appreciate it!